A look back at the week's health policy news with a
focus on ACA implementation
More on SCOTUS and other threats to the ACA, surveys and
more surveys, and in case you haven't heard, open enrollment starts tomorrow
(so we better talk about that). (With
the focus on those stories, I’ve made the other sections shorter than most
weeks.) Let’s get started.
ACA: Court Cases/Opposition
There have been no concrete developments since the Supreme
Court announced last week they would take one
of the ACA subsidy cases. But that hasn't
kept people from writing and speculating. Here’s a sample: Some are trying to reassure
us (Eight
Reasons to Stop Freaking Out About the Supreme Court's Next Obamacare Case),
some are trying to give us advice (How
states could avert a Supreme Court Obamacare disaster), some are warning us
of the ramifications (A
bad SCOTUS ruling could deepen polarization of health care system and Here's
What the Supreme Court Could Do to Insurance Premiums In Your State) and
some are trying to give advice to the Chief Justice (How
John Roberts Can Preserve His Conservative Cred and Save Obamacare at the Same
Time).
To me, this is a much more serious threat than any of us
thought when the first suit was brought.
We’ll talk about Congress below but I think SCOTUS is the more serious
threat. That said, my crystal ball is
broken so I really have no idea what will happen. In the coming weeks and months we’ll see a
lot more speculation, but at the end of the day no one really knows what those
nine men and women are going to do. (OK,
we probably have a pretty good idea what eight of them will do, but we still
don’t know the outcome.)
Amidst all the talk about the case, you might have heard
reference to Jon Gruber (The
Jon Gruber controversy and what it means for Obamacare, explained) (that’s
Jon, not Hans of Die Hard fame: The
Hans-Gruber-Story!). Short version,
he is an MIT economist who contributed to the design of RomneyCare and of the
ACA (the degree of his contribution is subject to debate), he is also the guy
who wrote the ACA comic book. He does not have much of a filter on what he
says; videos and quotes of his have been seized by the laws opponents to try
and show how bad the ACA is and how the President pulled one over on the
American people. Sigh. For those interested in the gory details of
what he said, here are some additional sources: Congress
Relies on the "Stupidity of the American Voter" All the Time:
Obamacare is just one of many examples—and both parties do it, The
Jonathan Gruber Controversy and Washington’s Dirty Little Secret (“Legislators
frequently game policy to fit the sometimes arbitrary conventions by which the
Congressional Budget Office evaluates laws and the public debates them.”) and
finally a reminder that The
Obamacare Debate Was One of the Most Transparent in Recent Memory.
Meanwhile, Congress is still at it. This week the House
GOP Re-Ups O-Care Repeal Bill After Big Election Wins (because 50 votes were not enough). In the Senate we
have An
army of one: Ted Cruz is leading the charge against Obamacare. But no one's
following. Here is a reminder Why
Republicans Will Vote to Repeal Obamacare, But Not on How To Replace It (basically
they know how hard real reform is and don’t want to open themselves to the same
type of criticism they’ve been making for the past six years). Here’s a reminder of some of the Republican
Alternatives To Obamacare (from last year courtesy of The Onion ;) ) And
here is a report of a new alternative that may be coming Rubio,
Ryan crafting Obamacare alternative.
And finally, one writer’s thoughts on The
congressional deal that could save Obamacare. I have two comments on the idea, 1) I’d take
the deal, 2) no one has offered it (and I’m not holding my breath while I
wait).
ACA: Polls
In the ramp up to open-enrollment, several new surveys that
shed light on what people think about their new coverage, what those still
uninsured are planning and how ready we all are to use out health coverage.
First, from Gallup: Newly
Insured Through Exchanges Give Coverage Good Marks “Americans who obtained
new health insurance policies in 2014 using the government exchanges are
roughly as positive about their healthcare coverage and the quality of
healthcare they receive as the average insured American, and are more satisfied
with the cost of their coverage. More than two-thirds of the newly insured who
purchased coverage through federal or state exchanges intend to renew their
exchange policies, while another 7% plan to look for a different policy through
the exchanges.”
Next, also from Gallup: In
U.S., 55% of Uninsured Plan to Get Health Coverage “55% of uninsured plan
to get health insurance, 35% say they will pay the fine for not having
insurance, and seven in ten are aware of requirement to have insurance”
And finally from Kaiser: Assessing
Americans' Familiarity With Health Insurance Terms and Concepts. Kaiser
also gives you the chance how you would stack up with the Health Insurance Quiz
which will show you how you’re responses stack up to the survey results.
ACA: Premiums
We've had indications earlier, but also as part of the ramp
up to open-enrollment, two new studies looking at premiums: First
Look at Health Insurance Rates for Next Year Is Encouraging “That’s the
conclusion of two studies of data about newly public insurance rates. One, from
the Kaiser Family Foundation, a health research group, looked at 49 cities and
found that prices for a popular type of plan are actually going down, on
average. A second, from the actuarial firm Wakely Consulting Group, looked at
the largest county in each of the 34 states with marketplaces run by the
federal government and found an average rate increase of zero.”
Of course we've known for a while that rates here in Maine
were very stable, it’s good to see many other parts of the country (but not
all) are seeing similar positive results.
ACA: Marketplaces
Let’s start with the basics (feel free to skip ahead if you
know all this). Open enrollment begins Saturday November 15th and
will last three months instead of six. This
year the website should work. Finding
new customers will be harder since those most motivated enrolled the first time
around. Returning customers will need to renew their coverage (and many will be
auto-reenrolled if they don’t shop around).
According to the National Review, these are The
3 Biggest Questions for Obamacare’s Second Year: 1) will the website work,
2) will existing customers shop around, 3) how many will sign up. All important questions! In the Marketplace
section this week, we’ll take a look at each one, then I’ll provide links to some
resources.
The Website
All signs point to a better experience than last year (could it be worse? I remember last year sitting at a computer at 5 AM hitting refresh and starting to panic…). The site has been tested over the past several weeks and while no one is saying it will be perfect, the administration is expressing confidence it will be good (HealthCare.gov Can Now Handle Twice As Many Shoppers, Obama Administration Says). At the same time forgoing last year’s hubris, Obama officials work on health site contingency plans as enrollment nears. Not an expectation of failure, but appropriate contingency planning. Among the improvements, it’s now very easy to look at plans and rates without registering (Consumers now able to window-shop for insurance on HealthCare.gov).
Existing Customers
This is going to be complicated… As with most insurance, individuals enrolled
in Marketplace plans will need to reenroll every year. Plans change each year as do rates and an
individual’s needs. In addition to all
that, about 80% of enrollees are receiving subsidies. Those subsidies will change each year based
both on the individual’s circumstances and based on what plans are offered at
what price (the subsidies are always based on the second cheapest silver plan available).
Faced with all that, everyone with a current plan is
encouraged to update their personal financial information (to determine the
correct subsidy) and to shop available plans (instead of defaulting to their
current plan). The Feds will
auto-reenroll the majority of people if they don’t do so, but that could be
problematic: Surprises
Lurk for People Re-Enrolling on HealthCare.gov “In a twist, an influx of lower-priced health
plans on HealthCare.gov could lead many Americans to pay more for coverage next
year thanks to smaller insurance tax credits.”
We’ll be watching closely to see how this goes.
How many will sign up
Last year the Feds enlisted celebrities and generally made a
lot of noise as enrollment started. This
year The
selling of Obamacare 2.0 will be a
lot quieter, if no less important, as the Feds will be more targeted in their approach.
The feeling seems to be that there needs to be less work
telling everyone about the law (not sure I agree, but they didn’t ask me). Enroll America, one of the leading national
organizations involved, saw Donations
drop for ObamaCare enrollment (their budget is $20 million down from $27
million last year).
So what will the number be?
HHS revealed new estimates that are lower than CBOs estimates from
several years ago: Estimate
of Health Coverage Enrollment Leaves Room to Grow.
Here is the actual projection: How Many
Individuals Might Have Marketplace Coverage After The 2015 Open Enrollment
Period? (Primary Source). And here
is the reliable Tim Jost’s take: Implementing
Health Reform: New HHS 2015 Marketplace Enrollment Estimates – he reviews
the estimates, thinks they are probably low.
Given the HHS range of 9-10 million is probably conservative, I think
the top end of the range is a safe estimate.
(Yes, this is in writing, you can mock me if I’m wrong.)
Resources
- Health Insurance Explained: The YouToons Have it Covered (the basics from Kaiser)
- The most confusing words in your health insurance forms, explained (from Vox)
- Affordable Care Act Enrollment FAQs (from the NY Times)
- Kaiser Health Insurance Marketplace Calculator calculate your subsidy, now updated with 2015 premium data
- Web Briefing For Journalists: Consumer Issues Ahead Of The Affordable Care Act’s Second Open Enrollment Season Handy facts in the PowerPoint available on the site
ACA: Employers
We’ve known for a while that the small business marketplace
(SHOP) was not successful last year, here are some numbers underscoring that
fact: O-Care
enrollment lags for small businesses. With
increased functionality, there is hope that things will get better this year (Small
Business Insurance Exchanges Seek Rebound).
Also this week some clarifications from CMS and the IRS
regarding what employers can and can’t do (Implementing
Health Reform: Defining Group Health Plans And More). These notices confirm what we've been saying,
that there is no way for an employer to give employees pre-tax dollars to
purchase subsidized coverage in the individual Marketplace.
ACA: Other
You may recall that there were issues in Florida with accusations
that insurance companies were using their drug formularies to discriminate
against individuals with certain conditions (such as HIV). This week without admitting any wrongdoing, Cigna
Agrees to Reduce H.I.V. Drug Costs for Some Florida Patients.
Also this week an in depth look at The
Family Glitch through a RWJ Foundation Health Policy Brief. And a review of Who
is still uninsured under Obamacare — and why.
Costs
We’ll start our cost discussion this week with a focus on
affordability. A new Commonwealth Fund
study shows that Even
with Health Insurance, Many Americans Find It Hard to Pay for Health Care “More than one of five 19-to-64-year old adults who
were insured all year spent 5 percent or more of their income on out-of-pocket
costs, not including premiums, and percent spent percent or more. Adults with
low incomes had the highest rates of steep out-of-pocket costs. About three of
five privately insured adults with low incomes and half of those with moderate
incomes reported that their deductibles are difficult to afford. Two of five
adults with private insurance who had high deductibles relative to their income
said they had delayed needed care because of the deductible.”
While some have criticized the ACA for this state of
affairs, Don't
blame Obamacare for high deductible plans Remember, “”It was not uncommon
before last year to see nongroup plans with $10,000, $15,000, or $20,000
deductibles," says Karen Pollitz, a health-insurance researcher at the
Kaiser Family Foundation.”
In addition to deductibles, consumers also grapple with the
issue of in vs out of network charges: Network
Blues: Big Bills Surprise Some E.R. Patients. The Maine Exchange Advisory
Committee included recommendation that this issue be investigated to see if it
is happening in Maine, although given current conditions in Augusta it is
unclear of those recommendations will be carried out.
The affordability issue are important, but in this
continuingly partisan political environment, I’m not holding out much hope of
them being addressed.
ACOs continue to make the news, here in Maine the
announcement of a new effort by Anthem (Insurer
reform on doctor reimbursements benefits patient care). And reports of other efforts finding success
in Massachusetts: To
lower health costs, change the ways doctors get paid “… a new study by
Harvard Medical School researchers has concluded that the accountable care
effort by the insurance provider Blue Cross Blue Shield of Massachusetts is
indeed bending the curve of health care spending.”
But not all efforts are created equal: High
Quality, Affordable Care: Making The Case For Smarter Networks “In the
following blog post, I argue that policymakers should consider that there are
different types of narrow networks and should be careful not to adopt policies
that inhibit new contractual arrangements among payers, providers, and
hospitals, such as Accountable Care Organizations, which hold the promise of
better quality care at lower cost. At the same time, issuers must provide
accurate and current information on which hospitals and providers are in the
network and are accepting new patients, and must make the case that smarter
networks can lead to better outcomes at lower cost.”
And we must be cautious as to what claims we believe, always
demanding evidence: JAMA
Forum: Hospital Consolidation Isn’t the Key to Lowering Costs and Raising Quality.
EBOLA
The tragedy of Ebola continues in Western Africa. But here, the U.S.
is now Ebola-free, and the panic is gone as well. There are now NO Ebola patients in the US as
both Dallas and NY put their incidents behind them (Dallas
Closes the Door on Its Ebola Scare and Plenty
of Hugs as Craig Spencer, Recovered New York Ebola Patient, Goes Home).
To me it is a sign that in spite of a few initial stumbles,
we appropriately handled the issue. But
if that were the case, why the panic (and the possible impact that panic had on
the elections)? Here’s one take on Why no
one could calm your Ebola fears — and why that mattered in this crisis “…
when we face an uncertain prospect that we deeply fear, we evince what Cass
Sunstein calls "probability neglect": we tend to conflate the horror
of what might happen with the likelihood that it will.”
One of the victims of that panic here in Maine announced
that now that her 21 days had passed and she continued to be disease free, she
is moving (Ebola
nurse Kaci Hickox moving to southern Maine). But there are continuing impacts of the panic
as Ebola
Volunteers Wrestle With Quarantine Mandates. As the outbreak continues and
the need for American volunteers remains, what harm will our fears do to the
efforts to end the crisis everywhere?
Medicaid
Interesting theorizing this week on if the Feds
Have New Leverage in Medicaid Showdown. Can they use lower payments for
uncompensated care – which are supposed to be reduced in light of Medicaid
expansion – to encourage states to proceed with expansion?
Regardless, we will see More
States Expected To Expand Medicaid in 2015.
But will they include Florida and Texas (Florida
Hospitals Could Lose Billions Without Medicaid Expansion, Group Warns and Perry-Appointed
Board Backs Health Coverage Expansion )?
More evidence of the positive impact expansion can have as
in Iowa, Medicaid
expansion slashes hospitals’ uninsured burden “the number of hospitalized
Iowans lacking health insurance dropped by nearly half in the first six months
of the year, mainly because the state decided to expand its Medicaid program,
hospital leaders said Wednesday.”
One of the knocks on Medicaid is that recipients can’t get
good care. But is there really a Shortage
of Medicaid Doctors? Not if You Ask Patients.
Medicare
Both good and bad news from Medicare this week. On the positive side a look at How
The Health Law Is Using Medicare To Improve Hospital Quality and Medicare
Proposes Covering Lung Cancer Screening. While disturbing news of waste as Doctors
Cash In on Drug Tests for Seniors, and Medicare Pays the Bill.
VA
Since Veterans’ Day was this week, seems like a good time to
check in on the Veterans’ Administration.
Things are not improving as fast as some had hoped leading some to ask Is the New VA Secretary Already Losing His Luster? Meanwhile, the Secretary is
trying to recruit more providers to help improve the system (Needing
to Hire, Chief of V.A. Tries to Sell Doctors on Change).
Drugs
More focus on generic drug pricing this week Justice
Department Probes Generic Companies After Price Hike Reports and Generic
drug competition and pricing nightmares.
We’ll see if it leads to any changes.
System Transformation
A new study found that email would be a good way for doctors
and patients to communicate. But How
To Get Doctors To Email Their Patients?
Spoiler alert! You make it a reimbursable service (pay them to do it).
Electronic communications and records are a fact of life,
but that doesn't mean we know how to build them (or use them) correctly (Electronic
Medical Records, Built For Efficiency, Often Backfire and Your
electronic health record may lack vital information).
And some still have trouble getting their hands on their own
information: Medical
Records: Top Secret
Finally, on a lighter note, a reminder that just because you
want social media to behave a certain way is no guarantee it will behave that
way. Dr.
Oz gets what's coming to him on Twitter
(and for more examples Here's what
happened when Dr. Oz asked Twitter for health questions).
All
comments and suggestions are welcome; please let me know what you think. And as always, thanks for reading!
Funded by support from
the Maine Health Access Foundation
*The title is a tribute to the BBC show, the NBC show and the amazing Tom Lehrer album "That Was The Year That Was"
